Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs. 1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities. 2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks". 2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required. PROBLEM Patients with complex medical issues encounter various barriers to health care 2 because the health care system is complex that may result in systemic failure and compromised patient safety. 4 These barriers to care are at patient, provider, and systems level, involving limited patient knowledge, resource constraints , and communication issues. 5 These systemic failures among national and global health institutions are identified in different transitions of care. 6 BACKGROUND Amongst the major priorities of healthcare are improving individual patient care, improving the health of populations, and reducing overall healthcare costs in accordance to the Triple Aim as described by the Institute for Healthcare Improvement. 3 Clients with complex medical and psycho-social issues are the greatest threat to any healthcare system. These factors not only affect health and quality of life, but are also major drivers of health care costs, threatening health care affordability. 7 These concerns have led to a public focus and an increase in research studies. The topics searched related to this program were on risk screening tools, risk assessment factors, case management models, interventions aimed at avoiding readmission, advanced care planning, and team communication and collaboration. Many institutions have been unsuccessful in implementing these models because of th...